More than 500,000 women died during pregnancy and childbirth in 1995 – and many more millions suffered without treatment. Large as the problem is, resolving it might not be as difficult as many believe.
Every minute of every day, somewhere in the world, a woman dies following pregnancy - related complications – 514,000 deaths each year. For every woman who dies, many more suffer disabilities that can affect them for the rest of their lives. The neglect that contributes to the deaths of women also compromises the health and survival of the infants they are carrying and the older children they leave behind.
Deaths during pregnancy or childbirth are unlike other deaths in developing countries. They happen only to young women, not because of disease, but during what should be a normal process. Childbirth is of course part of human survival and should be an event for the mother to celebrate. Society has a duty, therefore, to ensure that women are able to go safely through pregnancy and childbirth. But as women continue to die, it is a failure of their societies, their health systems and their families and communities.
The overwhelming majority of the more than half a million maternal deaths each year occur in developing countries. In the developed world, the maternal mortality ratio averages around 21 maternal deaths per 100,000 live births. By contrast, in developing countries the ratio is 20 times higher, at 440 per 100,000. While these numbers are subject to margins of uncertainty, there is no question that the risk of maternal death is most acute in sub-Saharan Africa and in parts of south-east Asia. In some regions, such as eastern and western Africa, the ratio may be as high as 1,000 deaths per 100,000 live births. In fact, a woman in Africa faces a one in 16 chance of dying from pregnancy-related causes; by contrast, for her sister in the developed countries, the risk is one in 2,500. The discrepancy between these two figures is one of the widest differentials between rich and poor countries, wider even than the gaps in child mortality.
Maternal deaths are all the more tragic because they can be prevented in simple and cost-effective ways. Infections, blood loss and unsafe abortion account for the majority of deaths; all these causes are well within the abilities of health workers with midwifery skills to tackle. The management of infection, shock, blood loss and convulsions, and surgical procedures, such as caesarean delivery, do not require high technology equipment or expensive drugs.
Alone in labour
There is a strong association between levels of maternal mortality and the proportion of births that are assisted by a skilled health care worker. Indeed, the proportion of births attended by skilled personnel is a key indicator for tracking progress in reducing maternal mortality. Globally, just over half of all deliveries are attended by a skilled birth assistant; for many of the rest, mothers will have the help of relatives or traditional birth attendants; millions deliver entirely alone. Poor mothers are much less likely to have access to a skilled birth attendant than richer ones; they are therefore more likely to die too.
The development goal is to change all that, by having skilled attendants at 90% of births by 2015 in regions where they are not routinely available. It is a tough challenge, since progress has been relatively modest over the past decade (see graphs), with an average annual increase in care coverage at delivery of under 1% in 1988-1998. Significant improvements in coverage have occurred in some countries, notably Bolivia, Egypt, Indonesia and Morocco, but in sub-Saharan Africa as a whole, there has been a decline. It is a disturbing trend and is probably caused by barriers to access like high cost of services and drugs, transport difficulties (including costs) and distrust of the services that are provided.
When $3 goes a long way
Reducing maternal mortality is not necessarily dependent on economic development. It would cost only about $3 a person a year in low-income countries to provide the essential services needed to tackle the problem: that would cover a skilled health worker to assist every delivery, access to essential obstetric care for mothers and their infants when complications arise, and family planning information and services so that unwanted pregnancies and unsafe abortions can be avoided.
No country is so poor that it cannot afford the key interventions needed. Indeed, no country can afford not to put resources and energy into safe motherhood, for as other articles in this Spotlight show, neglect of women drives poverty and robs the next generation of hope for a better future. What is lacking is not the level of national wealth, but the level of commitment to do something. Conscious decisions are required; China, Cuba, Iran, Malaysia and Sri Lanka have all been able to achieve and maintain significant reductions in levels of maternal mortality by deliberately allocating the resources where they were needed.
Decision-makers at political, economic, social, religious and household levels (which tend to be dominated by men) have to realise that pregnancy and childbirth can and should be made safer. After all, the very fabric of their societies depends on it.
©OECD Observer No 223, October 2000